Gallstones disease in surgery power point

Gallstone disease in surgery

1. GALLSTONE DISEASE IN SURGERY Kirengo T. ST3 MBChB MBA MSc MRCS(Ed)

2. INTRODUCTION Prevalence of up to 25% in the Western population Risk factors Presentation: Asymptomatic (majority) Biliary colic/ pain Complicated gallstone disease Clinical approach: Investigation Management 5/4/24 2

3. CAUSE Types: Cholesterol (37-86%). Pigment (2-27%), Calcium (1-17%), Mixed (4-16%) Imbalance in pronucleating and antinucleating factors in bile: Excessive cholesterol Low bile salt level Dec. gallbladder motility Low phosphatidylcholine levels (inhibits cholesterol crystallization) 5/4/24 3

4. RISK FACTOrS (Fat, female, FERTILE, forty) Female Pregnancy High - dose estrogen treatment Inc. Age Western population & diet Obesity Genetic/ Hereditary High serum Triglyceride levels & Cholesterol Rapid Wt. loss Lack of physical activity Crohn’s, Ileal resection (dec. bile salt re-absorption in ileum) Pigment stones: Hemolysis (sickle cell), parasitic infections, chronic bacterial infections 5/4/24 4

5. terminology 5/4/24 5

6. Asymptomatic gallstones 5/4/24 6

7. Biliary colic/ pain Intense dull pain/ discomfort in the RUQ or epigastric Pain is often non-colicky but constantly dull, but may come and go Pain may radiate to back, RT should and chest Aggravated by fatty meals, ?worse at night Associated with n+v Patient otherwise well No signs of infection: fever or tachy Atypical symptoms: Bloating, Reflux, Heartburn, Abd distention Examination: RUQ tender or normal depending on time of presentation 5/4/24 7 This Photo by Unknown Author is licensed under CC BY-NC

8. Investigations Lab - Normal FBC LFTs- Bili, ALP, Amylase/ Lipase CRP Imaging USS – recommended Tansabdominal (90% sensitive, 88% specific) or EUS (sludge/ microlithiasis) CT Scan –atypical patients, other issues suspected Less sensitive in detection of gallstones (50-80%) Can only detect calcified stones 5/4/24 Biliary colic/ pain 8

9. Management Biliary Colic/ Pain 5/4/24 9

10. Acute cholecystitis Most common complication of gallstones RUQ pain and infection Murphy sign: tenderness in the RUQ below the costal margin on deep inspiration; *Chronic cholecystitis- chronic inflammatory changes on histology Complications: Gangrene Perforation Emphysematous cholecystitis Cholecystoenteric fistula Gallstone ileus 5/4/24 10

11. investigations Lab FBC – Leukocytosis ⬆️ LFTs- Bili, ALP, Amylase/ Lipase CRP – Elevated ⬆️ Imaging – gallbladder wall thickening (>4mm), fluid USS – transabdominal or EUS (sludge/ microlithiasis) CT Scan – pericholecystic fat stranding MRCP - high sensitivity in detecting stones Acute cholecystitis 5/4/24 11

12. MANAGEMENT Abx Supportive care: IVI Analgesia Cholecystectomy NICE guidelines – w/ i same admission/ 1week IR/ Cholecystostomy Elderly, frail Permanent or cholecystectomy >3 months Acute cholecystitis 5/4/24 12

13. Cbd stones +/- acute cholangitis Pain Jaundice Acute cholangitis – if infection is present Charcot triad (50-75%)– RUQ pain, fever, Jaundice Reynolds Pentad- Additionally hypotension, mental status change Micro- Gram - ve - E. coli (25-50%), Klebsiella (15-20%) Grame + ve - Enterococcus (10-20%) Risk of complications: Sepsis, multiorgan failure 5/4/24 13 This Photo by Unknown Author is licensed under CC BY-NC-ND

14. investigations Lab FBC - Leukocytosis LFTs- Bili (conjugated) ⬆️, ALP ⬆️, Amylase/ Lipase CRP – Elevated ⬆️ Coagulation – PT/INR Blood cultures Imaging USS CT Scan MRCP CBD sones +/- acute cholangitis 5/4/24 14

15. MANAGEMENT Abx Supportive care: IVI Analgesia Cholecystectomy and: CBD exploration or ERCP before or After ERCP Percutaneous drainage CBD stones +/- acute cholangitis 5/4/24 15

16. Gallstone pancreatitis Obstruction & bile reflux to pancreatic duct: Pancreatic duct or Ampulla Severe Upper Abdominal Pain N+V Fever, tachypnoea, tachycardia, hypoxemia, hypotension Mild (localized symptoms) to Severe (persistent organ failure >1) 5/4/24 16

17. investigations Lab FBC - Leukocytosis LFTs- Bili ⬆️, ALP ⬆️, Amylase/ Lipase ⬆️ ⬆️ ⬆️ CRP – Elevated ⬆️ Imaging USS CT Scan MRCP Gallstone pancreatitis 5/4/24 17

18. MANAGEMENT Supportive care: IVI Analgesia ITU ERCP Cholecystectomy +/- CBD exploration Gallstone pancreatitis 5/4/24 18

19. Other issues 5/4/24 19

20. Differential diagnosis Peptic ulcer disease – epigastric pain, heartburn, bloating Sphincter Oddi Dysfunction (SOD) – no stones, no infection, abN LFTs, dilated CBD Functional gallbladder disorder – diagnosis of exclusion Post-cholecystectomy syndrome – ongoing symptoms post-cholecystectomy 5/4/24 20

21. ROLE OF MEDICAL RX? RCT evidence & systematic reviews shows low rate of cure (<30%) and high recurrence (>50%) with: Extracorporeal shockwave lithotripsy Bile acid dissolution therapy with ursodeoxycholic acid In patients unfit for surgery, consider: IR percutaneous drainage/ cholecystostomy ERCP 5/4/24 21

22. Case scenarios Bleep for patient admitted under medics. No abd pain, USS incidentally found 9mm gallbladder polyp? ED calls for patient review: in 50s, jaundiced, reported fever now settled, and had RUQ pain. Approach? SDEC GP calls: Female, in late 30s, abd pains on & off, heartburn, nausea, no fevers. What next? Review bloods and scan: SC B7186908 5/4/24 22

23. CONCLUSION 5/4/24 23

24. questions 5/4/24 24

25. references NICE guidelines 2014 Gallstones: BMJ 2014;348:g2669 Gallstones in adults. Uptodate Gallstones. Medscape Girometti R, Brondani G, Cereser L, Como G, Del Pin M, Bazzocchi M, Zuiani C. Post-cholecystectomy syndrome: spectrum of biliary findings at magnetic resonance cholangiopancreatography. Br J Radiol . 2010 Apr;83(988):351-61. doi : 10.1259/ bjr /99865290. PMID: 20335441; PMCID: PMC3473449. 5/4/24 25